Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case.

BACKGROUND: Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration. OBSERVATIONS: A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well. LESSONS: Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Surgical treatment of marginal sinus dural arteriovenous fistula: a narrative review.

BACKGROUND: Dural arteriovenous fistulas of the marginal sinus (DAVFms) are uncommon and complex, with varied symptoms. Their complexity is heightened by the region's dense anastomotic network, posing risks for endovascular treatment. Surgical intervention can be effective, but this depends on thorough pre-operative understanding and optimal intra-operative visualization of the fistula. OBJECTIVE: To review the relevant anatomy, presentation patterns of DAVFms, and provide insights for surgical treatment. METHODS: Recent literature on DAVFms was reviewed, and three surgical cases are discussed to highlight treatment principles. RESULTS: The symptoms of a DAVFms vary depending on its venous drainage pattern. Drainage may be either ascending towards the cranial compartment or descending towards the spinal canal. Patients suffering from DAVFms may experience hemorrhage, particularly when venous drainage is directed upwards. Congestive symptoms of the spinal cord or brainstem can occur in cases of downward venous drainage. Compared to the endovascular approach, open surgery has a higher success rate in obliterating the fistula and yields better outcomes in cases of perimedullary venous drainage. Achieving surgical success necessitates thorough preoperative evaluation and adequate surgical exposure. Brainstem hyperintensity observed on T2-weighted MRI scans is linked to a poorer prognosis for recovery. CONCLUSION: Treating complex DAVFms often requires surgery, as endovascular methods may not be feasible. Successful surgery hinges on a precise understanding of the fistula's venous architecture and its spatial relationships, assessed using digital substraction angiography (DSA), angio-MRI, and angio-CT. Optimal intraoperative exposure is crucial for effective surgery.

Microsurgical Management of a Marginal Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

Dural arteriovenous fistulas (DAVFs) are benign but may present with life-threatening hemorrhage or symptoms of venous hypertension (eg, progressive myelopathy).1-3 DAVFs follow well-described anatomic patterns.4 The marginal sinus is located between the layers of the dura, circumferentially around the foramen magnum. It communicates with the basal venous plexus of the clivus anteriorly and the occipital sinus posteriorly.5,6 Arterial supply to the dura in this region that fistulizes into the sinus arises from meningeal branches from the V3 or V4 segments. A man in his early 70s presented with chronic neck pain and new onset of left arm and face paresthesias. He had brisk patellar reflexes bilaterally and a marginal sinus DAVF, with numerous dilated veins around the cisterna magna, causing dorsal cervicomedullary compression. Angiography confirmed the diagnosis of DAVF rather than arteriovenous malformation. Endovascular embolization was considered, but surgery was preferable because of poor transarterial access. The patient underwent left far lateral craniotomy and C1 laminectomy with exposure of the condylar fossa. The dura was carefully elevated laterally, revealing a network of dilated tortuous veins, with multiple points of fistulous connection within the dura emanating in a large venous varix. Indocyanine green videoangiography showed the aberrant flow dynamics. The fistulous point was occluded with aneurysm clips on the venous side, then cauterized and interrupted. The patient was discharged within 3 d of surgery and had full resolution of symptoms at 6 wk. Angiography confirmed complete obliteration of the DAVF. The patient provided written informed consent for treatment. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Development of the paratympanic pneumatic system of Japanese quail.

Avian heads are characterized as having two extensive air-filled systems lined with epithelia; the paranasal and paratympanic sinuses. Many diverticula derived from the paratympanic sinus system are known to reticulate with each other to form a single merged pneumatic space within the adult braincase. However, the development of these complex branching and reticulating epithelia has not been examined in detail. In this study, we describe the comprehensive developmental pattern of the paratympanic sinus and its associated soft tissues in a model bird, Japanese quail (Coturnix japonica). The data are derived from three-dimensional reconstructions based on histological sections and soft tissue enhanced micro-CT data. Those data provide the foundation of the complex hierarchical developmental pattern of the paratympanic sinus system. Moreover, associations with other tissues help establish key morphologies that identify each pneumatic entity. This study clarifies the developmental relationships of the ventral portions of the paratympanic sinus system, the siphoneal diverticulum and marginal sinus, based on the ligaments associated with the Eustachian tube. In addition, detailed histological pneumatic morphologies reveal hitherto unknown epithelial diversity, which may be indicative of equally complex developmental processes. We use the pneumatization of the quadrate as an example to support a close relationship with vascular growth and pneumatic epithelia invasion into ossified bone. We confirm pneumatic diverticula never enter into cartilages, possibly due to the absence of vasculature in these tissues. Lastly, we use the concept of a morphogenetic tree as a tool to help present the complex developmental pattern of the paratympanic sinus system and apply it toward inferring pneumatic morphologies in a nonavian theropod braincase.

Results of 1940 embolizations for dural arteriovenous fistulas: Japanese Registry of Neuroendovascular Therapy (JR-NET3).

OBJECTIVE: Embolization is the most common treatment for dural arteriovenous fistulas (dAVFs). A retrospective, multicenter observational study was conducted in Japan to clarify the nature, frequency, and risk factors for complications of dAVF embolization. METHODS: Patient data were derived from the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET3). A total of 40,169 procedures were registered in JR-NET3, including 2121 procedures (5.28%) in which dAVFs were treated with embolization. After data extraction, the authors analyzed complication details and risk factors in 1940 procedures performed in 1458 patients with cranial dAVFs treated with successful or attempted embolization. RESULTS: Transarterial embolization (TAE) alone was performed in 858 cases (44%), and transvenous embolization (TVE) alone was performed in 910 cases (47%). Both TAE and TVE were performed in one session in 172 cases (9%). Complications occurred in 149 cases (7.7%). Thirty-day morbidity and mortality occurred in 55 cases (2.8%) and 16 cases (0.8%), respectively. Non-sinus-type locations, radical embolization as the strategy, procedure done at a hospital that performed dAVF embolization in fewer than 10 cases during the study period, and emergency procedures were independent risk factors for overall complications. CONCLUSIONS: Complication rates of dAVF embolization in Japan were acceptable. For better results, the risk factors identified in this study should be considered in treatment decisions.

Descended marginal sinus of the placenta.

This is the first reported case of descent of the placental marginal sinus through the cervix to the external os. We think marginal sinus rupture does exist. The definition of placental edge should be the parenchyma in diagnosis of low-lying placentation. Clinically, however, the low-lying marginal sinus should be treated similar to low-lying placentation.

Marginal sinus placenta previa is a different entity in placenta previa: A retrospective study using magnetic resonance imaging.

OBJECTIVE: The current definition of placenta previa does not include whether the placental edge is parenchyma or marginal sinus defined as placenta previa in which the placental marginal sinus just reached the internal os and/or in which the placental parenchyma might be located at > 2 cm from internal os. MATERIALS AND METHODS: Cases with placenta previa were identified through the review of magnetic resonance imaging (MRI) from among 210 cases at our institution between 2007 and 2016. The clinical outcomes of patients with marginal sinus placenta previa (Group A) were compared with patients with low-lying placenta and marginal placenta (Group B) and patients with partial placenta and total placenta previa (Group C), respectively. This study was a retrospective analysis. RESULTS: Twenty-seven (12.7%) cases were included in Group A. The patients in Group B and Group C were 72 and 108 cases, respectively. First, Group A more frequently underwent emergency cesarean section than Group B (p = 0.02). There was no statistical significance with other maternal history, post-or pre-operative hemorrhage, and/or additional treatment for hemorrhage between the two groups. Additionally, Group A delivered at a later gestational age (p < 0.01); were less frequently complicated with antenatal bleeding (p < 0.01); underwent emergency cesarean section (p < 0.01), allogenic blood transfusion (p < 0.01), and uterine artery embolization (p < 0.01) for postpartum hemorrhage less often; and had less perioperative hemorrhage (p < 0.01) than Group C. CONCLUSIONS: Marginal sinus placenta previa may be a mild type of placenta previa. This new classification could be useful in the management of placenta previa.

Surgical Microanatomy of the Posterior Condylar Emissary Vein and its Anatomical Variations for the Transcondylar Fossa Approach.

BACKGROUND: It is essential to identify and be aware of the anatomy of the posterior condylar emissary vein (PCEV) for achieving an adequate operative field for the transcondylar fossa approach (TCFA). OBJECTIVE: To describe the variations in the drainage patterns of PCEVs and the technical issues encountered in such cases. METHODS: This was a retrospective analysis of the anatomy of PCEVs in 104 sides in 52 cases treated by the TCFA. Preoperative findings of multidetector-row computed tomography (CT) and CT venography (CTV) were compared with the intraoperative findings. The drainage patterns were classified as 5 types: the sigmoid sinus (SS), jugular bulb (JB), occipital sinus (OS), anterior condylar emissary vein (ACEV), and marginal sinus (MS). RESULTS: The SS, JB, ACEV, and OS types were observed in 33 (31.7%), 42 (40.3%), 8 (7.7%), and 1 (1.0%) side(s), respectively. One side (1.0%) each had combined drainage from MS and JB, and ACEV and JB, respectively. In 17 sides (16.3%), the PCEVs and posterior condylar canals could not be identified on CT and CTV. CONCLUSIONS: Preoperative CT and CTV findings correlated well with the intraoperative findings. To make a sufficient operative field for TCFA, PCEVs should be appropriately dealt with based on the preoperative knowledge of their running course, pattern, and origin.

Planned vaginal delivery versus planned cesarean delivery in cases of low-lying placenta.

OBJECTIVE: To assess the applicability of trial of labor in cases of low-lying placenta. METHODS: In this observational cohort study, we collected data from the women with low-lying placenta delivered at our hospital between April 2012 and December 2015. Low-lying placenta was diagnosed when the length from the placental lowest edge to the internal cervical os (placenta-os distance) was 0-20 mm at 36 gestational weeks. Planned mode of delivery for each case was determined by patient's preference. Maternal and neonatal outcomes were compared between the planned vaginal delivery group (N = 11) and the planned cesarean delivery group (N = 7). RESULTS: All the women in the planned cesarean delivery group underwent scheduled cesarean section at 37-38 gestational weeks. Three cases in the planned vaginal delivery group required emergency cesarean section for uncontrollable antepartum bleeding. The intrapartum blood loss was significantly smaller in the planned vaginal delivery group than in the planned cesarean delivery group (946 ± 204 g vs. 1649 ± 256 g, p = 0.047). Umbilical arterial blood pH was similar between the two groups. All the women requiring emergency cesarean section were accompanied by marginal sinus. CONCLUSIONS: Trial of labor can be offered to all the women with low-lying placenta except for those accompanied by marginal sinus.

Dominant Occipital Sinus Complicating Surgery of a Fourth Ventricular Mass.

BACKGROUND: We describe a case of a fourth ventricular mass requiring a modified approach to its management owing to a rare variation of the occipital sinus (OS). CASE DESCRIPTION: A 32-year-old female presented with persistent headache and nausea. Magnetic resonance imaging revealed a fourth ventricular mass and hydrocephalus. Venous sinus anatomy appeared unusual, and thus magnetic resonance venography was performed, which identified the OS as the main drainage pathway for the entire brain, providing the sole drainage between the superior sagittal sinus and the jugular veins through the marginal sinus. Both the transverse and sigmoid sinuses were hypoplastic, and flow through the straight sinus was diminished. Thus, endoscopic third ventriculostomy and biopsy were performed as the first step. Postoperatively, the patient's nausea persisted and biopsy results were inconclusive, and thus a second surgery was planned. The dural opening was tailored so as not to damage the OS and marginal sinus, and the tumor was resected subtotally through the limited dural opening. Histopathological analysis identified a low-grade glioma. CONCLUSIONS: Rare variations of the venous/sinus anatomy may fundamentally change the surgical management plan, and recognizing such variations is crucial to minimizing the risk of potentially fatal complications.

Marginal sinus fistula supplied exclusively by vertebral artery feeders.

A 54-year-old woman is reported with severe pulsatile tinnitus. Digital subtraction angiography demonstrated dural arteriovenous fistula of the marginal sinus with feeders arising exclusively from bilateral vertebral arteries. Patient underwent successful transarterial Onyx embolization with complete angiographic and clinical cure.